Standing Practice Order – Formal Appeals – Provides information and instruction regarding the pre-hearing procedures for matters that have been docketed as Formal Appeals before the Bureau of Hearings and Appeals. This document also contains a list of Legal Services Corporations.
Standing Practice Order – Medical Assistance Provider Appeals – Establishes rules governing practice and procedure in Medical Assistance provider appeals.
Procedure for Telephonic Testimony in Formal Cases
You can search Bureau of Hearings and Appeals decisions on Medical Assistance provider appeals. Most of the documents listed in this search are in Portable Document Format. If you have trouble accessing this information you may obtain an alternative format by contacting the Bureau of Hearings and Appeals (717-783-3950) and requesting a publication
“Formal Appeals” refers to approximately 100 jurisdictional issues concerning the Department of Public Welfare (or the Department of Aging) but not relating to benefits for individual recipients or applicants, such as Cash Assistance or Supplemental Nutrition Assistance Program (SNAP) benefits, formerly known as Food Stamps.
The following is a summary listing of the general categories of appeals processed by the Formal Pre-Hearing Unit:
- Act 142 Medical Assistance Provider appeals
- Act 534 – Denial or termination
- Adoption – Assistance waiver; denial of approval; denial of subsidy
- Audit – Appeal from an audit determination
- Child Abuse – Appeal from a report of child abuse; child abuse report expungement
- Foster Care – Denial of approval as a foster care home; relocation of a child in foster care
- Licensure – Child Day Care Facility Licensure denial or revocation; issuance of a provisional license to operate a child day care, personal care boarding home, or mental health/mental retardation facility
- MA Preclusion – Preclusion by the Department of Public Welfare for health care providers to participate in the PA Medical Assistance Program
- Aging – Report of elder abuse; pharmacy appeals relating to the PACE program
The Formal Pre-Hearing Unit is responsible for the pre-hearing processing of all formal type appeals received by BHA. Pre-hearing processes include: pre-screening for adherence to state and federal filing requirements, docketing, data entry, scheduling and conducting telephonic pre-hearing conferences and possibly a timeliness hearing. If a full hearing on the merits is needed, the date of such a hearing may be determined during the pre-hearing conference. Formal notices of a hearing are sent to the parties regarding the date, time, and location of the hearing. The file and all accompanying documentation are forwarded to the appropriate region prior to the hearing date.
The Administrative Regional Manager oversees this unit which consists of four Administrative Law Judges, three Legal Assistants 2 (Formal Docketing Coordinators), and two Legal Assistants who work together to ensure the timely and proper handling of formal appeals received by the BHA.
To determine if you have the right to appeal and/or if BHA has jurisdiction over the matter which you dispute, reference Pennsylvania regulations at www.pacode.com or www.pabulletin.com.
The Bureau of Hearings and Appeals has the authority delegated by the Secretary of Public Welfare to hear and adjudicate over 280 jurisdictional issues for the Department of Public Welfare. The Bureau is also designated to hear and adjudicate issues for the Department of Aging under an interagency agreement. The issues under Bureau of Hearings and Appeals jurisdiction include, but are not limited to, the following:
- Denial, reduction, suspension, or termination of Cash Assistance, Medical Assistance or Supplemental Nutrition Assistance Program (SNAP) benefits, formerly known as Food Stamps.
- Denial, reduction, suspension, or termination of direct social services (e.g. day care, legal services, etc.).
- Denial of PACE prescription benefits by the Department of Aging.
- Denial, reduction, or termination of Department of Aging Adult Day Care services.
- Appropriate level of care for nursing home residents.
- Denial, suspension, or termination of providers from participation in the Medical Assistance Program.
- Liability of payment for persons who are either receiving in-patient or out-patient care in mental health facilities.
- Denial, suspension, or termination of licensure for personal care boarding home facilities or day care facilities.
- Employee injury claims under Act 534.
- Establishment of family service plans for persons receiving services through the local children and youth agency.
- Adoption subsidy cases and foster care benefit cases.
- Disputes regarding the maintenance of the permanent record of founded or indicated child abuse in the central state registry.
- Nursing rate reimbursement (either the establishment of per diem rates or audit resolution issues).
- In-patient utilization review.
- Provisions of Low Income Home Energy Assistance cash payments.
- Disputes regarding reports of elder abuse to the Department of Aging.
All hearings regarding recipient related appeals are conducted in accordance with the regulations found at Title 55 Pa. Code, Chapter 275 (and 6 Pa. Code, Chapter 3 for Department of Aging appeals). Recipient claims should be filed with the program office. Hearings for non-recipient related appeals are conducted in accordance with Title 1 Pa. Code Chapters 31, 33 and 35, and Medical Provider appeals are conducted under Title 55 Pa. Code Chapter 41.
Recipient Appeal Process
When the Department of Public Welfare (DPW) or the Department of Aging notifies the applicant or recipient that benefits or payments have been denied or will be reduced, suspended or terminated, he or she has the right to request a fair hearing to dispute the adverse action. Appeals must be filed in written format, except in Supplemental Nutritional Assistance Program (SNAP), formerly Food Stamp, cases. An oral appeal can be filed to dispute an adverse action regarding SNAP benefits.
The Bureau of Hearings and Appeals conducts the fair hearings and decides the DPW applicant and recipient appeals and the appeals from Department of Aging adverse actions. The Bureau currently receives approximately 45,000 to 60,000 appeals per year. Appeals are filed with program offices, which process and track them, then forward them to BHA. Appeals must be forwarded to the Bureau within three workdays of receipt by the program offices.
When an appeal is received by the Bureau, it is docketed and scheduled for a hearing to be conducted by an Administrative Law Judge. When a hearing date has been assigned, a written notice is sent to both parties, i.e. the appellant and to the departmental program office. In appropriate cases, DPW’s Office of General Counsel (OGC) is also notified of the hearing.
Hearings may be conducted over-the-telephone or in person. Most recipient cases are handled via telephone. In Philadelphia, more of the hearings are held in person, i.e., the appellant and the DPW’s representative travel to the regional Bureau office and the hearing is conducted by the Administrative Law Judge with the parties present. Hearing method (telephone or in person) is the appellant’s preference. Whether in person or over-the-telephone, hearings are conducted in accordance with 55 Pa. Code, Chapter 275 (and also 6 Pa. Code, Chapter 6 in Aging appeals).
The responsibilities of the Administrative Law Judge include conducting the hearing in an orderly but informal manner and obtaining testimony and documentary evidence from the parties. The Administrative Law Judge may choose to make an oral decision on the appeal at the hearing. The oral decision at the hearing is called a bench decision. If the Administrative Law Judge decides the appeal with a bench decision, the Administrative Law Judge will issue a short written decision. If the Administrative Law Judge does not choose to issue a bench decision, the Administrative Law Judge prepares a written decision (adjudication) based upon the facts and evidence. The decision or recommendation contains a statement of the issues, findings of fact, a discussion and a ruling of the Administrative Law Judge. The adjudication of a DPW applicant or recipient appeal is then subject to review by the Director of the Bureau and can be affirmed, amended, reversed or remanded. In a Department of Aging appeal, the Administrative Law Judge writes an adjudication in the form of a proposed report to the Secretary of the Department of Aging (or Chief Counsel designee). The Secretary of Aging or Chief Counsel designee may accept the proposed report immediately or issue it to the parties to file exceptions to (i.e. arguments against) the proposed report. The parties have 30 days to submit any exceptions. At the end of the 30 days, the Secretary of Aging or Chief Counsel designee will issue a Final Order to accept the proposed report or reverse it.
Either party to a DPW applicant or recipient appeal (unless the issue under appeal is food stamp related, then only the appellant may request reconsideration) may seek reconsideration by the Secretary of Public Welfare of the final order of the Director of the Bureau by requesting such within 15 calendar days from the date of the final order. Generally, only the appellant has the right to seek review by the Commonwealth Court of Pennsylvania of any decision by the Director of BHA. The appellant may seek reconsideration and petition Commonwealth Court simultaneously. If the Appellant elects to request reconsideration only, his or her right to petition Commonwealth Court is still preserved pending the Secretary’s decision on reconsideration. Should the Secretary find in favor of the appellant, the appropriate party(ies), where permitted, may take issue with the adjudication, and Order, and may petition the Commonwealth Court of Pennsylvania within 30 days from the date of the order. The petition must be filed with the Clerk of Commonwealth Court of Pennsylvania, 601 Commonwealth Avenue, Suite 2100, P.O. Box 69185, Harrisburg, PA 17106-9185. However, if the Secretary finds for DPW, the appellant may seek review before the Commonwealth Court of Pennsylvania. If Commonwealth Court review is sought, the DPW’s legal counsel represents the program office or agency involved in the dispute.